ModifiedCignaPolicy 0510

Transthoracic Echocardiography (TTE) and Related Cardiac Imaging - Coverage and Coding Guidance

Coverage and coding guidance for transthoracic echocardiograms (including myocardial strain imaging CPT 93356) and the ICD-10-CM diagnosis codes that support medical necessity for multiple TTEs within a 12-month period; applies to Cigna's policy audience (providers/billers).

Policy Summary

PayerCigna

PolicyTransthoracic Echocardiography (TTE) and Related Cardiac Imaging - Coverage and Coding Guidance

Policy CodePolicy 0510

Change TypeRevised policy statementreference removaleditorial updates

Effective Date

Next Review DateFeb 15, 2025

Key ActionWhen more than two TTEs are billed within a rolling 12 months, bill with a covered diagnosis code from the policy tables and meet applicable policy criteria.

SourceLink

POLICY UPDATE CHANGES

Revised policy statement to include individuals undergoing nonemergent, noncardiac surgery, and to include the diagnosis and management of hypertrophic cardiomyopathy.

Removed the 2017 Multimodality Imaging in Valvular Heart Disease Appropriate Use Criteria (AUC) from the policy statement.

Editorial update to references listed in policy statement. No change to intent of coverage.

>2TTEs allowed within a rolling 12 months when criteria met

93356CPT for myocardial strain imaging listed as medically necessary when criteria met

108Covered diagnosis codes listed (Table 2 excerpts)

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9/AMany high-priority evaluation or surveillance recommendations

AnnualPolicy review cadence

Coverage and Medical Necessity Criteria

Coverage criteria not included in this document part

Coverage criteria not included in this document part — The detailed coverage criteria for some indications referenced in this section are not reproduced here. When making coverage determinations, reviewers must refer to the full policy statements and associated tables and code lists found elsewhere in the complete policy document.

All imaging requests for transthoracic echocardiography (TTE) and myocardial strain imaging (CPT 93356) must be accompanied by clinical documentation supporting the indication, applicable guideline alignment, and relevant diagnosis codes.

If a requested service or diagnosis code is not listed in the covered ICD-10-CM tables elsewhere in the policy, the service is Not Covered or Reimbursable unless an evidence-based guideline or explicit policy statement provided in the complete policy supports coverage.

Frequency limitations (for example, >2 TTEs in a rolling 12-month period) and other utilization rules described in separate policy statements apply; absence of an explicit criterion in this section does not imply coverage.

For indications or scenarios not fully described within this section (including some surveillance intervals, specific postprocedural timing, or detailed lesion-specific guidance), apply the applicable guideline recommendations cited in the full policy (ACC/AHA/ASE AUCs and specialty guidelines) and the operational rules documented elsewhere in the policy.

Documentation note: When no clinical indication, guideline recommendation, or FDA timeline exists to justify surveillance beyond routine intervals, the request requires additional documentation explaining the clinical rationale and supporting evidence.

Operational note: This section does not reproduce the full ICD-10 exclusion lists; billing and coding staff should consult the code tables in the complete policy before claim submission.

Codes and Billing Guidance

Covered ICD-10 Codes (Table 2 excerpts)ICD-10Covered

A36.81	Diphtheritic cardiomyopathy
A39.51	Meningococcal endocarditis
A39.52	Meningococcal myocarditis
A39.53	Meningococcal pericarditis
A52.03	Syphilitic endocarditis
B33.21	Viral endocarditis
B33.22	Viral myocarditis
B33.23	Viral pericarditis
B33.24	Viral cardiomyopathy
B37.6	Candidal endocarditis

1–10 of 117

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Provider Responsibilities, Authorization & Documentation

Prior Authorization

Limit on TTE Frequency — >2 TTEs/12 months require criteria and diagnosis linkage

More than two transthoracic echocardiograms (TTEs) within a rolling 12-month period are considered medically necessary only when the applicable policy criteria are met and the services are billed with a covered diagnosis code from the policy tables.

Prior Authorization

CPT 93356 Coverage Requires Policy Criteria and Supported Diagnosis

CPT 93356 (myocardial strain imaging) is considered medically necessary only when the applicable policy criteria are met and it is billed with one or more of the specified supporting diagnoses listed in the policy.

Note

Timing Guidance — Postprocedural (≈30 days) and Variable Surveillance Intervals

The policy provides recommended timing for routine postprocedural TTE (for example, within 30 days after repair) and a range of routine surveillance intervals, but these excerpts do not specify discrete payer prior authorization code-level requirements.

Background and Scope

This policy section enumerates the ICD-10-CM diagnosis codes that justify transthoracic echocardiography (TTE) and related echocardiography services and provides frequency guidance. Notably, it states that more than two TTEs within a rolling 12 months are considered medically necessary only when the applicable policy criteria are met and the service is billed with a covered diagnosis code; it also affirms CPT 93356 (myocardial strain imaging) as medically necessary when the applicable criteria and diagnosis linkage are met.

Definitions and Terms

Myocardial strain imaging (CPT 93356)

CPT code93356 — Myocardial strain imaging using speckle-tracking-derived assessment of myocardial mechanics; list separately in addition to echocardiography imaging codes.

Coverage conditionCPT 93356 is considered medically necessary only when applicable policy criteria are met and it is billed with one or more of the specified supporting diagnoses.

Billing note93356 is reported in addition to echocardiography imaging codes (listed separately).

Myocardial strain

DefinitionMyocardial strain is the deformation produced by application of force; it represents the percent change in myocardial length from relaxed to contractile state.

Measurement variabilityStrain values vary among methods, imaging modalities, and software versions.

Policy Revision History

Annual Review (date not specified in excerpt)annual_reviewLatest

Policy underwent annual review with editorial updates to references and clarifications to policy statement intent; operational coverage intent was updated to explicitly add indications including individuals undergoing nonemergent, noncardiac surgery and hypertrophic cardiomyopathy management.

2024-10-08guideline_reference_added

Referenced the 2024 Appropriate Use Criteria for multimodality imaging in nonemergent, noncardiac surgery to align imaging appropriateness guidance with updated AUC statements.

Policy Summary

PayerCigna

PolicyTransthoracic Echocardiography (TTE) and Related Cardiac Imaging - Coverage and Coding Guidance

Policy CodePolicy 0510

Change TypeRevised policy statementreference removaleditorial updates

Effective Date

Next Review DateFeb 15, 2025

Key ActionWhen more than two TTEs are billed within a rolling 12 months, bill with a covered diagnosis code from the policy tables and meet applicable policy criteria.

SourceLink

On This Page

Postprocedural TTE commonly recommended within 30 days (see congenital and postoperative tables).
Surveillance intervals vary by lesion and age (examples in tables: 1 week to multiple years).

Note

Timing Recommendations Provided — No Explicit Prior Authorization Listed

These sections give timing recommendations for surveillance and evaluation (routine surveillance, evaluation for change in clinical status, pre- and postprocedural assessments) but do not list specific prior authorization requirements in the provided excerpts.

Note

ACC AUC Referenced — No Code-Level Prior Authorization Specified Here

The excerpt references ACC Appropriate Use Criteria to define indications and appropriateness ratings for TTE and strain imaging, but it does not specify payer-level prior authorization or code-level requirements in these chunks.

Prior Authorization

High-Appropriateness: Stroke/TIA Evaluation and PFO/ASD Preprocedure Imaging

Initial evaluation to exclude a cardiac source of TIA/stroke and preprocedural assessment for PFO/ASD are rated highly appropriate and should be supported by clinical documentation when seeking coverage.

Initial TTE to exclude cardiac origin of TIA/stroke (including intracardiac masses, vegetations) rated 8/A.
Preprocedural PFO assessment (atrial appendage thrombus, septal anatomy) rated 7/A.

Prior Authorization

Reference Routine Post-Procedure Surveillance Intervals in Authorization

Authorization requests should reference routine postprocedure surveillance timepoints when applicable: routine 6-month TTE after ASD/PFO device closure (with agitated saline as needed) and surveillance at ~45 days after LAA occlusion are specified.

6-month routine follow-up after ASD/PFO device closure (TTE with agitated saline) rated 7/A.
Surveillance at ~45 days after LAA occlusion to assess device stability and exclude complications.

Prior Authorization

Prosthetic Valve Evaluation — Baseline and Periodic Surveillance; Urgent Imaging for Suspected Thrombosis

Guidelines recommend a baseline postprocedural TTE for patients with prosthetic valves and periodic monitoring thereafter; urgent imaging (TTE/TEE/CT) is indicated for suspected prosthetic valve thrombosis or acute dysfunction.

Baseline postprocedural TTE is recommended for prosthetic valves.
Bioprosthetic surgical valves: TTE at 5 and 10 years and then annually is reasonable; TAVI: annual TTE reasonable.
Urgent evaluation with TTE/TEE/fluoroscopy/CT for suspected prosthetic valve thrombosis is indicated.

Note

No Prior Authorization Codes Specified in These Chunks

This portion of the document (part 10/revision notes) does not identify specific codes requiring prior authorization in the provided excerpts.

Step Therapy

No Step Therapy Specified

No step therapy requirements for TTE or CPT 93356 are specified in the provided excerpts.

Documentation Required

Imaging Selection for VAD Complications — Document Modality and Rationale

When evaluating suspected ventricular assist device (VAD) complications or infection, select imaging modalities appropriately and document modality choice (e.g., consider FDG PET for suspected infection) alongside TTE/advanced imaging as clinically indicated.

Re-evaluation for VAD-related complication or infection: TTE rated 8/A; FDG PET noted for infection detection.

Step Therapy

Stepwise Imaging — TTE First for Suspected HCM and New Heart Failure

For initial evaluation of suspected hypertrophic cardiomyopathy (HCM) or newly diagnosed heart failure, perform a transthoracic echocardiogram (TTE) as the first-line imaging test before other advanced modalities.

TTE is recommended in the initial evaluation of suspected HCM (COR:1) and in suspected or newly diagnosed heart failure (COR:1).

Step Therapy

Use Contrast (UEA) When ≥2 Contiguous Segments Are Not Visualized

If TTE image quality is limited (two or more contiguous segments cannot be properly visualized), use an ultrasound enhancing agent (UEA) to improve endocardial delineation before proceeding to alternative imaging modalities.

UEA recommended when two or more contiguous segments are not properly seen.

Documentation Required

Diagnosis Linkage Required When >2 TTEs/12 months

When more than two TTEs are billed within a rolling 12-month period, the provider must bill the services with a covered diagnosis code from the policy's listed tables and ensure the encounter meets the applicable policy criteria.

Documentation Required

Documentation Required When Billing CPT 93356 — Criteria and Diagnosis Linkage

When billing CPT 93356 (myocardial strain imaging), document that the applicable policy criteria are met and bill with one or more of the policy-specified supporting diagnoses for medical necessity.

93356 must be listed separately in addition to echocardiography imaging codes.
Ensure one or more of the listed ICD-10 diagnoses accompany the claim.

Documentation Required

Preprocedural PFO/ASD Assessment — Document Thrombus, SEC, Aortic Atheroma, Septal Anatomy

Preprocedural assessment for PFO/ASD should document evaluation of atrial appendage thrombus, spontaneous echo contrast (slow flow), aortic atheroma, cardiac masses/vegetations, and atrial septum anatomy including atrial septal aneurysm and suitability for percutaneous device closure.

Document atrial appendage thrombus and spontaneous echo contrast.
Document atrial septum anatomy, atrial septal aneurysm, and suitability for device closure.

Documentation Required

LAA Preprocedural Elements — Document Thrombus, Morphology, Dimensions

Preprocedural imaging documentation should include assessment for LA/LAA thrombus and LAA morphology/dimensions as applicable, alongside the other standard preprocedural elements.

Assess LA/LAA thrombus and spontaneous echo contrast.
Record baseline LAA dimensions, ostial morphology, and dominant lobe length when relevant.

Documentation Required

Support Clinical Indication in Documentation (Symptoms, Exam Changes, ECG, Suspected IE, Valve Symptoms)

Clinical documentation supporting the imaging request should describe the signs, symptoms, or clinical context that justify the exam (for example, symptoms or signs of AS/AR/MR, changes in symptoms or cardiac examination findings, pathological ECG changes, heart murmur, or suspected endocarditis).

Denial Risk

Denial Risk — Unsupported Diagnosis Codes May Be Not Covered

Claims submitted with diagnosis codes that are not listed in the policy's covered ICD-10-CM tables may be classified as Not Covered or Reimbursable and are at risk for denial.

Denial Risk

Not Covered Diagnosis Codes — Billing With Excluded Codes Risks Denial

The policy contains 'Not Covered or Reimbursable' sections listing ICD-10 diagnosis codes that may not be covered; billing with those codes can result in noncoverage or denial.

Denial Risk

Low Appropriateness — Routine Re-evaluation <1 Year Without Clinical Change

Routine re-evaluation TTE performed in less than one year for patients without a change in clinical status or cardiac examination is generally rated low appropriateness (2/R) and may not be supported.

Denial Risk

Follow-Up Imaging Must Be Justified — 6-Month ASD/PFO Surveillance vs Nonroutine Indications

Lack of documented clinical indication for routine 6-month follow-up imaging after ASD/PFO device closure, or absence of clinical concern for nonroutine follow-up (infection, malposition, embolization, persistent shunt), could lead to denial of additional imaging beyond routine surveillance.

6-month routine scheduled follow-up after device closure is appropriate; nonroutine imaging requires clinical concern (infection, malposition, embolization, persistent shunt).

Denial Risk

Prosthetic Valve Surveillance — Adhere to Baseline and Periodic Monitoring Recommendations

Failure to perform recommended baseline postprocedural or periodic surveillance TTE for prosthetic valves (including suggested bioprosthetic schedules and annual TAVI evaluation) may conflict with guideline-based expectations for follow-up and surveillance.

Bioprosthetic surgical valves: TTE at 5 and 10 years then annually is reasonable.
Bioprosthetic TAVI: annual TTE reasonable.

Clinical useMost prevalent use is identification of cancer therapy–related cardiac dysfunction; supported by ACC and literature for cardiotoxicity surveillance.

Transthoracic echocardiography (TTE)

Core componentsA standard TTE exam begins with real-time 2D imaging and may include spectral Doppler (pulsed/continuous), color flow Doppler, tissue Doppler, 3D imaging, contrast enhancement, and myocardial strain imaging.

PurposeProvides high-resolution, multiplane real-time visualization of cardiac structures, valve function, and hemodynamics.

ModalitiesTTE technique family includes 2D, Doppler, color flow, tissue Doppler, 3D, and strain modalities used as clinically indicated.

Routine surveillance

DefinitionRoutine surveillance: scheduled TTE follow-up in asymptomatic patients at defined intervals based on diagnosis and severity (examples range from 1 week to 3–5 years).

ExamplesExamples include routine surveillance after device closure (1 week, 1 month, 3–6 months, 1 year, 2–5 years) and valve/lesion-specific intervals in congenital heart disease tables.

ApplicabilitySurveillance intervals vary by lesion, age, severity, and postprocedural status as specified in the policy tables.

Evaluation due to change in clinical status

DefinitionEvaluation due to change in clinical status: TTE performed for new or worsening signs/symptoms or clinical concerns; these evaluations are consistently rated highly (e.g., 9/A).

When to performIndicated for new concerning symptoms, suspected complications, or when findings warrant re-assessment (pre-repair and acute changes).

Contrast roleTTE with contrast may have different appropriateness ratings but is considered in evaluation depending on clinical context and image quality.

Routine surveillance (lesion/age-specific intervals)

Lesion- and age-specific intervalsExamples: infants with any mitral stenosis: 1–4 weeks; infants with ≥ moderate mitral regurgitation: 1–3 months; LVOT lesions: infants 1–4 weeks to 3–6 months depending on severity.

Postprocedural first-year planPostprocedural TTE commonly performed within 30 days, with additional surveillance at 1 week, 1 month, 3–6 months, 1 year and beyond as tabled for specific lesions.

Variability by lesionSurveillance timing differs across CHD categories (e.g., annual for some coronary anomalies, 2–5 year intervals for stable bicuspid aortic valve), per tables 10–19.

Postprocedural evaluation

Postprocedural windowPostprocedural evaluation: routine TTE within 30 days after surgical or catheter-based intervention to assess device position and complications.

Subsequent follow-upAdditional scheduled follow-up examples include 6-month and 45-day assessments for ASD/PFO and LAA devices respectively, with longer-term surveillance per tables and guidelines.

IndicationsPostprocedural imaging indicated for device integrity, pericardial effusion, thrombus, valve function, and changes in clinical status.

Routine surveillance intervals

Routine intervals applied to CHDRoutine surveillance intervals applied to congenital diagnoses include ranges such as 1–4 weeks, 1–3 months, 3–6 months, 6–12 months, 1–2 years, and 3–5 years depending on diagnosis and severity.

High-appropriateness for change in statusEvaluation due to change in clinical status and pre-repair assessments are generally rated 9/A across CHD tables.

Contrast ratingsMany TTE-with-contrast entries in congenital tables are not rated or have lower appropriateness compared with standard TTE.

Strain/Strain Rate Imaging

DefinitionStrain/strain-rate imaging: advanced echocardiographic tissue deformation assessment (speckle tracking or tissue Doppler) listed separately from standard TTE with distinct appropriateness ratings.

Separate ratingsStrain imaging often has lower or different appropriateness ratings than standard TTE and is indicated in select scenarios (e.g., cardiotoxicity surveillance, suspected HCM).

TechniquesIncludes speckle-tracking and tissue Doppler methods; billed separately (CPT 93356) when performed in addition to TTE imaging.

TTE modalities

Modalities referencedTTE modalities referenced throughout tables include: TTE with or without 3D and with contrast as needed, depending on indication and image quality.

Use guidanceChoice of modality (3D, contrast) depends on the specific clinical scenario, lesion, and appropriateness ratings in the tables.

ReportingWhen contrast or 3D is used, appropriateness and scoring are provided separately in the applicable table rows.

Strain/Strain Rate Imaging by Speckle or Tissue Doppler

Technique typesStrain/strain-rate imaging may be performed by speckle tracking or tissue Doppler and is listed with distinct appropriateness ratings in the AUC tables.

Indication-specific ratingAppropriateness for speckle vs tissue Doppler strain techniques varies by indication; many scenarios list strain separately from standard TTE.

BillingWhen performed, report strain imaging (CPT 93356) separately in addition to TTE imaging codes as applicable.

LAA evaluation elements

LAA evaluation elementsPreprocedural LAA evaluation should assess all cardiac chambers, LV function, interatrial septum, valve function, LA/LAA thrombus, and spontaneous echo contrast; assess LAA morphology, ostial dimensions, and dominant lobe length as applicable.

Clinical purposeUsed to evaluate thrombus risk, anatomy for occlusion device sizing, and to guide procedural planning.

Modality noteTTE with or without 3D and with contrast as needed is recommended for preprocedural and postprocedural LAA assessment per tables.

PFO/ASD imaging elements

Assessment elementsPFO/ASD imaging should include evaluation for atrial appendage thrombus, spontaneous echo contrast, aortic atheroma, cardiac masses/vegetations, and detailed atrial septum anatomy including atrial septal aneurysm and suitability for percutaneous device closure.

Procedural roleTTE with agitated saline (bubble study), with or without 3D and contrast as needed, is recommended for preprocedural assessment and intraprocedural guidance depending on anatomy complexity.

DocumentationPreprocedural imaging documentation should explicitly note these assessment elements to support device closure planning.

Class of Recommendation (COR)

DefinitionClass of Recommendation (COR) indicates the strength of recommendation reflecting estimated magnitude and certainty of benefit relative to risk (e.g., Class I = strong/recommended).

UsageCORs are used throughout the policy tables to convey recommendation strength for imaging indications.

LevelsCommon classes include Class I (Strong), Class 2a (Moderate), Class 2b (Weak), and Class 3 (No benefit or Harm).

Level of Evidence (LOE)

DefinitionLevel of Evidence (LOE) rates the quality of scientific evidence supporting the intervention (e.g., Level A = high-quality randomized data; Level B-R/B-NR = moderate quality; Level C = limited/consensus).

InterpretationLOE complements COR to indicate confidence in recommended imaging based on available data.

ApplicationLOE categories (A, B‑R, B‑NR, C‑LD, C‑EO) are referenced in guideline-derived recommendations cited in the policy.

Guideline and reference sources

Sources listedPolicy references multiple guideline and evidence sources including CDC, CMS, ACC/AHA, ASE, AHA/ACC/HFSA, and specialty society recommendations used to inform imaging guidance.

Key guideline examplesCited works include ACC/AHA valvular disease guidelines (2020), AHA/ACC HCM guideline (2024), ACC/AHA aortic disease guideline (2022), and ACC Appropriate Use Criteria documents.

PurposeThese references support the appropriateness ratings, surveillance intervals, and procedural imaging recommendations in the policy tables.

guideline_reference_added

Added citation for the 2024 AHA/ACC Guideline for the Management of Hypertrophic Cardiomyopathy to support HCM-related imaging recommendations.

2022-12-13guideline_reference_added

Included the 2022 ACC/AHA Guideline for the Diagnosis and Management of Aortic Disease to inform surveillance and imaging intervals for aortic pathology.

2022-05-03guideline_reference_added

Cited the 2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure to support heart failure imaging and initial evaluation recommendations.

2019-02-05guideline_reference_added

Retained the 2019 ACC Appropriate Use Criteria for multimodality imaging in assessment of cardiac structure and function as a foundational reference for many appropriateness ratings in the policy.

This policy is reviewed annually and a focused review was recorded in the revision history. The revision details note editorial updates and a material update that explicitly added indications (including individuals undergoing nonemergent, noncardiac surgery and hypertrophic cardiomyopathy) to the policy statement.